Laserfiche WebLink
Waste Tire Survey & Inspection ReportP _PQ.._ <br /> ■ roe€: Ins ection Re rt Number <br /> State of California i <br /> ClWMB 181(New 04/04) Survey:Form - Page 1 I I - 1 Q .6446 <br /> m <br /> Cali6amis Integrated Waste Manageent Board -- - - -- - --' - <br /> Part A-Survey- BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> i <br /> Site Suffix: 6 l ;6 Y� L?�1 le Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier:. i I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ` p - _ '— <br /> Physical Address 1 f 7 L! 0 1 <br /> Inspection Ode. O 7 I ?: 6 i Q t S <br /> J <br /> Ci;y ---- - Time In -_ -- Time Out <br /> Business Rep Title :O AM 10 AM <br /> �,' �� O \ V �✓�� ? rage <br /> OIII one only)lStatus Tires Type aPPIY) (Brype <br /> FB 11 all that apply) (Tsine Roleill that PPIY) <br /> Tire Count(Whole/PTE) �. _ <br /> - WAcliye_- _ !_Passenger ®Generator S Outdoor <br /> O Q Closed Q Altered <br /> Latitude Q Hauler Q Indoor <br /> GPS O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) — <br /> Q New Tire Dealer 41 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility '° <br /> O <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q .Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decalin Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 .0 14 COR§18459.2.1 Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR'§1.8459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years . <br /> Q Q .4 CCR§18460.2.-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsk �& <br /> Other. § <br /> Q Q Oth <br /> Comments i u�1- p _ 1 • C J, 1 ws ( \ �S1ei�� <br /> Fa�cl�►/,,,.V�s %j+t+�ctr�-��Sa.i��.�� �vGala- `Ii,M`L�. _ _ <br /> 4ry )AA <br /> Inspection Form Included:Q , - 'fes`' <br /> Comments Included: Business Rep u e h ne Number Inspectr Phone Number: <br /> 62081 <br /> INSTRUCTIONS ON BACK B 7C IMP 'l- E:I 111213 ® ■ <br /> White Copy'.CIWMB Yellow Copy:Operator .Pink Copy:LEA <br /> 0525804.0170 <br />